Provider Demographics
NPI:1073051223
Name:LWBBA GRISSELL CHAIT LLAMAS MD INC
Entity Type:Organization
Organization Name:LWBBA GRISSELL CHAIT LLAMAS MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LWBBA
Authorized Official - Middle Name:GRISSELL
Authorized Official - Last Name:CHAIT LLAMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-351-3333
Mailing Address - Street 1:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:751 W LEGION RD
Practice Address - Street 2:SUITE 103
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-7732
Practice Address - Country:US
Practice Address - Phone:760-351-4100
Practice Address - Fax:760-351-4101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-08
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA138938208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB272417Medicare PIN